RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02507
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080523

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Basic Trainee, medically separated for “chronic right hip pain,” with a disability rating of 10%.

CI CONTENTION:  “Please consider all conditions.”  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is based upon a review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20080428	VARD - 20081124	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Hip Pain Post Femoral Neck Stress Reaction due to Trochanteric  Bursitis	5299-5255	10%	Trochanteric Bursitis, Right Hip, Residual of Femoral
Neck Stress Reaction (claimed as Trochanteric Bursitis;
Residual of Femoral Neck Stress Reaction)	5099-5019	NSC	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Chronic Right Hip Pain.  According to the limited service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s hip condition began in September 2007 after rifle marksmanship training.  Overtime it became progressively worse.  In October 2007 the CI underwent a bone scan which showed a focal uptake at the left sacroiliac joint consistent with a stress fracture, although the NARSUM indicated she was diagnosed with a right sacral fracture.  Additionally, there was mild focal uptake at both femoral necks consistent with mild stress fractures.  In October 2007, magnetic resonance imaging (MRI) of the hips demonstrated a left hemisacrum stress fracture and femoral neck stress reactions.  Treatment consisted of physical therapy and the use of crutches.  In January 2008, X-rays of the hips were negative, while a bone scan on 23 January 2008 showed small bilateral femoral neck stress fractures were still present; however, an MRI of the hips on 29 January 2008 demonstrated no evidence for a proximal femoral stress lesion, but there was mild bilateral trochanteric bursitis of both hips and a Bertolotti segment (lumbosacral transitional vertebra) on the right.

Despite treatment, the right hip condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “chronic right hip pain due to trochanteric bursitis and residual of femoral neck stress reaction” for PEB adjudication.

At the MEB examination (recorded on DD Forms 2807 and 2808) dated March 2008, 2 months prior to separation, the CI reported a “stress fracture sacrum” and “bursitis in hips.”  The examiner noted bilateral hip pain with passive range of motion (ROM).  At the MEB NARSUM examination dated 21 March 2008, 2 months prior to separation, the CI described flare-ups when she lifted weights and her hip pain became worse, but she did not describe any repetitive activities that made the hip pain worse.  On examination her gait and stance were normal.  There was mild tenderness over the greater trochanter without edema or other bony or soft tissue tenderness.  The ROM measurements were right hip flexion 94 degrees and 93 degrees left, right hip extension 21 degrees and 32 degrees left, and right hip abduction 21 degrees and 24 degrees left.  All limitations were due to pain and not weakness, lack of coordination or lack of endurance.  There was 5/5 strength in the extensors and flexors of both hips.  The CI was unable to return to basic training because of the inability to run or march and had flare-ups due to pain when lifting.  The examiner opined the CI was likely to have an additional 30 degrees limitation in flexion based on the difference between the active and passive ROMs due to flare-ups.   
  
The CI did not report for her initial VA Compensation and Pension (C&P) examination scheduled for 21 October 2008.  X-rays of the right hip on 5 January 2009 were normal.  At a VA C&P examination on 14 January 2009, performed 8 months after separation, the CI reported  pain in both hips with back stiffness and inability to rotate towards the back right or left.   The ROM measurements are in the chart below.  Pain was present with full abduction and positive psoas (muscle) movement.  An MRI of the lumbar spine demonstrated likely asymmetric sacralization of L5; otherwise it was unremarkable, while X-rays of the right hip showed the morphology of the femoral head suggestive of mild dysplasia; right sacroiliitis was not excluded.  

The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  
  
Right Hip (Thigh) ROM
In Degrees	PT ~3 Mo. Pre-Sep
	MEB~2 Mo. Pre-Sep
	VA C&P ~8 Mo. Post-Sep
	
Flexion (0-125⁰)	93/95/95	94	0-125	
Extension (0-20⁰)	20/22/21	21	0-130	
Internal rotation 40			0-40	
External Rotation (0-45⁰)			0-60	
Abduction (0-45⁰)	21/22/21	21	0-25	
Adduction (0-45⁰)			0-35	
Comment	Pain with motion; normal gait; able to cross legs bilaterally with pain	Limitations due to pain and 30 degrees of flexion with flares	Pain with full abduction and positive psoas movement	
§4.71a Rating	PEB 10%	10%	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5299-5255 code (femur impairment), citing chronic right hip pain post femoral neck stress reaction due to trochanteric bursitis.  The VA initially found the condition not service connected using an analogous 5099-5019 code (bursitis) based on the non-attendance at a VA C&P examination, citing trochanteric bursitis, right hip, residual of femoral neck stress reaction (claimed as trochanteric bursitis; residual of femoral neck stress reaction).  Thereafter, the VA assigned a 10% rating under an analogous 5252-5024 code (thigh limitation of flexion-tenosynovitis) based on the VA C&P examination 8 months after separation, citing right hip tendonitis status post stress fracture (claimed as Bertolotti’s syndrome).  Board members discussed alternative rating options; however, in the absence of hip ankylosis (code 5250), thigh limitation of extension (code 5251), thigh limitation of flexion (code 5252), thigh impairment (code 5253), hip flail joint (code 5254) or femur impairment with moderate knee or hip disability (code 5255), there was no route to a higher rating.  Board members also discussed whether the NARSUM examiner’s opinion that there could be an additional limitation of flexion of 30 degrees with flares would provide an alternative or additional rating.  Even with an additional limitation of 30 degrees, the Board did feel the CI’s condition rose to a moderate hip disability (code 5255) or could be rated higher on thigh limitation of flexion (code 5252) especially since at the VA examination, 8 months after separation, the flexion ROM was 0-125 degrees and there was no mention of flare-ups either by the CI or examiner.  Therefore, Board members determined the potential for flare-ups does not warrant a higher rating IAW DeLuca v. Brown.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the slight right hip disability condition.    

BOARD FINDINGS:  In the matter of the right hip condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140430, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander

16 NOV 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160016874 (PD201402507)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application.  

This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA